Provider Demographics
NPI:1689664591
Name:STEPHENS, JEFF (RPH)
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1322 AQUILA DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-2614
Mailing Address - Country:US
Mailing Address - Phone:719-214-3400
Mailing Address - Fax:
Practice Address - Street 1:1322 AQUILA DR
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2614
Practice Address - Country:US
Practice Address - Phone:719-214-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO13146183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO03000734Medicaid
0735960001Medicare NSC